Orville Boren is a 68-year-old African American who had a stroke

due to right cerebral thrombosis 1 week ago. He is a history in-

structor at the local community college. His hobbies are wood
carving and gardening. Mr. Boren is also an active member of his
church. For the past 2 years, Mr. Boren has been taking medication
for hypertension, but
his wife Emily reports that he often forgets
to take it an
d that his blood pressure was high at his last physical
examination. Mrs. Boren tells the staff that she has never had to
worry abou
t her husband’s health before and that she wants to
learn everything she can to care for him at home. However, she
says that her husband was always the one to make the decisions
and pay the bills. Mrs. Boren adds that all the children, grandchil-
dren, neighbors, and family pastor want to see Mr. Boren back at
home as soon as possible.
ASSESSMENT
Carol Merck, RN, t
he nurse assigned to Mr. Boren, completes a
health history and physical assessment, with Mrs. Boren provid-
ing information for the history. Mrs. Boren reports that her hus-
band did have several spells of dizziness and blurred vision the
w
eek before his stroke, but they lasted only a few minutes and he
believed them to be due to “old age and working out in the sun.”
On the morning of admission, Mr. Boren woke up and could not
move his left arm or leg; he also could not speak sensibly. Mrs.
Boren called 911, and an ambulance took her husband to the
hospital.
Physical
assessment findings include the following: Mr. Boren is
drowsy but responds to verbal stimuli. Although he does not re-
spond verbally, he can nod his head to indicate “yes” when asked
questions. Flaccid paralysis is present in his left arm and left leg,
with no response noted to touch in those extremities (he is left-
handed). Visual fields are decreased in a pattern consistent with
homonymous hemianopia. A CT scan, negative on admission, is re-
peated on the third day after admission and confirms the medical
diagnosis of a right-brain stroke due to a thrombus of the middle
cerebral
artery.
Mr. Boren’s medical treatment includes heparin sodium admin-
istered by continuous intravenous drip, with clotting studies to be
performed every 4 hours and the dose adjusted accordingly.
DIAGNOSES
•
F
eeding self-care deficit,
re
lated to loss of the ability to use the
left hand and arm
•
Impaired physical mobility,
related to neurolog
ic deficits caus-
ing left hemiplegia
•
R
isk for impaired skin integrity,
re
lated to inability to change po-
sition
•
Sensory/percep
tual alterations: visual,
related to
changes in vi-
sual fields
•
Impaired verbal communication,
related to ce
rebral injury
EXPECTED OUTCOMES
•Learn to us
e his right hand to feed himself.
•Participate
in exercises necessary to maintain muscle strength
and tone.
•Maintain skin
integrity.
•I
ndicate understanding that visual fields may improve in a few
w
eeks.
•P
ra
ct
ice and implement speech therapy activities while at the
same time using alternative methods of communication.
PLANNING AND IMPLEMENTATION
•Arran
ge mealtimes so that he is sitting up by the window in a
clean and private environment.
•P
ro
vide adaptive devices (silverware with thick handles and
nonslip plates).
•Enc
ourage Mrs. Boren to visit at mealtimes, to assist with meals,
and periodically to bring a favorite food from home.
•Provi
de passive ROM exercises for his left arm and leg; schedule
active ROM exercises for his right extremities as well as quadri-
ce
ps and gluteal sets every 4 hours during waking hours.
•K
eep his skin clean and dry at all times.
•Estab
lish and maintain a regular schedule for turning when he
is in bed.
•Place objec
ts (e.g., call bell, tissues) on unaffected side and ap-
proach him from that side.
•S
upport attempts to communicate verbally; when he is not un-
derstood, he prefers to use a large marker and tablet.
EVALUATION
Mr. Boren is discharged to his home after being in the hospital for
10 days. During the first 2 months after discharge, Martha Grimes,
RN, the home health nurse, visits Mr. and Mrs. Boren at home. At the
end of 2 months, Mr. Boren is using his right hand to feed himself.
He has regained partial use of his left arm and leg and is using a
walker to move around the house and yard; he is even able to work
in his flower garden. His skin has remained intact, and his vision is
back to normal. He is slowly relearning speech; this has been the
most difficult change for him to accept. Once he writes on his
tablet,“I think God has forgotten me.”
Critical Thinking in the Nursing Process
1. Hypertension is sometimes referred to as “the silent killer.”
Provide just
ifications for this statement.
2. The functional changes Mr. Boren has experienced may make
a return to teaching difficult. What other uses of his knowl-
edge and abilities might you suggest?
3. What would be your reply if, after you had completed passive
ROM on Mr. Boren’s left arm, he wrote: “I just ignore that part
of my body—it doesn’t work anyway”?
S
ee Evaluating your Response in Appendix C.